[ ] Original [ ] Amended [ ] Termination (1a)

State ____________1b________________________
Co./City/Dist. of ________1c___________________
Tribunal/Case Number _______________________

     Employer’s/Withholder's Name
     Employer’s/Withholder's Address
     Employer/Withholder's Federal EIN Number (if known)

RE:________ 3a_______________________ (4) Child(ren)'s Name(s): DOB
     Employee's/Obligor's Name (Lasts, First, MI)

     Employee's/Obligor's Social Security Number
     Employee's/Obligor's Case Identifier
     Obligee Name (Last, First, MI)

5 [ ] If checked, you are required to enroll the child(ren) identified above in any health insurance coverage available to the employee’s/obligor’s through his/her employment.

ORDER INFORMATION: This Order/Notice is based on the support order from [State] _______ (6)_____.
You are required by law to deduct these amounts from the employee’s/obligor’s income until further notice.

$ _______7a_______ Per _______7b____current child support   14
$ _______8a_______ Per _______8b ___ past-due child support - Arrears 12 weeks or greater? [ ]yes [ ]no
$ _______9a_______ Per _______9b___  current medical support
$ _______10a______ Per  ______10b___ past-due medical support
$ _______11a______ Per  ______11b___ spousal support
$ _______12a______ Per  ______12b___ other (specify) _____________12c __________________________
for a total of $ ____ 13a ________ per _______13b___________ to be forwarded to the payee below.

You do not have to vary your pay cycle to be in compliance with the support order. If your pay cycle does not match the ordered payment cycle, withhold one of the following amounts:

$15a per weekly pay period.                  $15c per semimonthly pay period (twice a month).
$15b per biweekly pay period (every two weeks).     $15dper monthly pay period.

REMITTANCE INFORMATION: When remitting payment, provide the pay date/date of withholding and the case identifier. If the employee’s/obligor’s principal place of employment is _____16______, begin withholding no later than the first pay period occurring 17 days after the date of ___18___. Send payment within ___19___ working days of the pay date/date of withholding. The total withheld amount, including your fee, cannot exceed 20% of the employee's/obligor's aggregate disposable weekly earnings.

If the employee’s/obligor’s principal place of employment is not 21 , for limitations on withholding, applicable time requirements, and any allowable employer fees, follow the laws and procedures of the employee’s/obligor’s principal place of employment (see #4 and #10, ADDITIONAL INFORMATION TO EMPLOYERS AND OTHER WITHHOLDERS).

If remitting payment by EFT/EDI, call_____22a_____before first submission. Use this FIPS code:_____22b_____: Bank routing code:____22c_____Bank account number:_____22d_____.

Make check payable to:______________23___________________________________________________
                                        Payee and Case Identifier
Send check to:______________24__________________________________________________________

Authorized by: _________________25a____________   Date:  _______________25b________________
                         ________________________________   Date: ___________________________________
Print Name and Title_______________26____________________________________________________
Of Authorized Official(s)___________________________________________________________________

IMPORTANT: The person completing this form is advised that the information on this form may be shared with the obligor.



27 [ ] If checked, you are required to provide a copy of this form to your employee. If your employee works in a state that is different from the state that issued this order, a copy must be provided to your employee even if the box is not checked.

1. We appreciate the voluntary compliance of Federally recognized Indian tribes, tribally-owned businesses, and Indian-owned businesses located on a reservation that choose to withhold in accordance with this notice.

2. Priority: Withholding under this Order/Notice has priority over any other legal process under State law against the same income. Federal tax levies in effect before receipt of this order have priority. If there are Federal tax levies in effect, please contact the State Child Support Enforcement Agency or party listed in number 12 below.

3. Combining Payments: You can combine withheld amounts from more than one employee’s/obligor's income in a single payment to each agency/party requesting withholding. You must, however, separately identify the portion of the single payment that is attributable to each employee/obligor.

4. Reporting the Paydate/Date of Withholding: You must report the paydate/date of withholding when sending the payment. The paydate/date of withholding is the date on which the amount was withheld from the employee's wages. You must comply with the law of the state of employee's/obligor's principal place of employment with respect to the time periods within which you must implement the withholding order and forward the support payments.

5. Employee/Obligor with Multiple Support Withholdings:If there is more than one Order/Notice to Withhold Income for Child Support against this employee/obligor and you are unable to honor all support Order/Notices due to Federal or State withholding limits, you must follow the law of the state of employee's/obligor's principal place of employment. You must honor all Order/Notices to the greatest extent possible. (See #10 below.)

6. Termination Notification:You must promptly notify the Child Support Enforcement Agency or payee when the employee/obligor no longer works for you. Please provide the information requested and return a complete copy of this order/notice to the Child Support Enforcement Agency or payee.
EMPLOYEE'S/OBLIGOR'S NAME:_________________________________CASE IDENTIFIER:___________
DATE OF SEPARATION FROM EMPLOYMENT:_________________________________________________
LAST KNOWN HOME ADDRESS:_____________________________________________________________
NEW EMPLOYER/ADDRESS:________________________________________________________________

7. Lump Sum Payments: You may be required to report and withhold from lump sum payments such as bonuses, commissions, or severance pay. If you have any questions about lump sum payments, contact the person or authority below.

8. Liability:If you have any doubts about the validity of the Order/Notice, contact the agency or person listed below. If you fail to withhold income as the Order/Notice directs, you are liable for both the accumulated amount you should have withheld from the employee’s/obligor's income and any other penalties set by State law.

9. Anti-discrimination:You are subject to a fine determined under State law for discharging an employee/obligor from employment, refusing to employ, or taking disciplinary action against any employee/obligor because of a child support withholding.

10. Withholding Limits:You may not withhold more than the lesser of: 1) the amounts allowed by the Federal Consumer Credit Protection Act (15 U.S.C. § 1673(b)); or 2) the amounts allowed by the State of the employee's/obligor's principal place of employment. The Federal limit applies to the aggregate disposable weekly earnings (ADWE). ADWE is the net income left after making mandatory deductions such as: State, Federal, local taxes, Social Security taxes, statutory pension contributions, and Medicare taxes.
Additional Information:______________________________30_______________________________________

11.Submitted by_____________________________31______________________________________________

12. If you or your employee/obligor have any questions, contact: ________32a_____________by telephone at _______32b_________________ or by FAX at __________32c______________________ or by Internet at ________________32d____________________

OMB: 0970-0154